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Analysing the history invariably guides the clinician to the diagnosis. The pain patterns have to be carefully evaluated and it is helpful to map the diurnal variations of pain to facilitate the diagnosis (see FIG. 38.3).
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It is especially important to note the intensity of the pain and its relation to rest and activity. In particular, ask whether the pain is present during the night, whether it wakes the patient, is present on rising or whether it is associated with stiffness.
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Continuous pain, present day and night, is suggestive of neoplasia or infection. Pain on waking also suggests inflammation or depressive illness. Pain provoked by activity and relieved by rest suggests mechanical dysfunction while pain worse at rest and relieved by moderate activity is typical of inflammation. In some patients the coexistence of mechanical and inflammatory causes complicates the pattern.
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Pain aggravated by standing or walking that is relieved by sitting is suggestive of spondylolisthesis. Pain aggravated by sitting (usually) and improved with standing indicates a discogenic problem.
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Pain of the calf that travels proximally with walking indicates vascular claudication; pain in the buttock that descends with walking indicates neurogenic claudication. This latter problem is encountered more frequently in older people who have a tendency to spinal canal stenosis associated with spondylosis.
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What is your general health like?
Can you describe the nature of your back pain?
Was your pain brought on by an injury?
Is it worse when you wake in the morning or later in the day?
How do you sleep during the night?
What effect does rest have on the pain?
What effect does activity have on the pain?
Is the pain worse when sitting or standing?
What effect does coughing or sneezing or straining at the toilet have?
What happens to the pain in your back or leg if you go for a long walk?
Do you have a history of psoriasis, diarrhoea, penile discharge, eye trouble or severe pain in your joints?
Do you have any urinary symptoms?
What medication are you taking? Are you on anticoagulants?
Are you under any extra stress at work or home?
Do you feel tense or depressed or irritable?
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The basic objectives of the physical examination are to reproduce the patient’s symptoms, detect the level of the lesion and determine the cause (if possible) by provocation of the affected joints or tissues. This is done using the time-honoured method of joint examination— look, feel, move and test function. The patient should be stripped to a minimum of clothing so that careful examination of the back can be made. A neurological examination of the lower limb should be performed if symptoms extend below the buttocks. It is important to perform a rectal examination to check for flaccidity in a patient with suspected cauda equina syndrome.
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A useful screening test for a disc lesion and dural tethering is the slump test.7
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The main components of the physical examination are:
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inspection
active movements:
forward flexion (to reproduce the patient’s symptoms)
extension (to reproduce the patient’s symptoms)
lateral flexion (R & L) (to reproduce the patient’s symptoms)
provocative tests (to reproduce the patient’s symptoms)
palpation (to detect level of pain)
neurological testing of lower limbs (if appropriate)
testing of related joints (hip, sacroiliac)
assessment of pelvis and lower limbs for any deformity (e.g. leg shortening)
general medical examination, including rectal examination
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The surface anatomy of the lumbar region is the basis for determining the vertebral level. Key anatomical landmarks include the iliac crest, spinous processes, the sacrum and the posterior superior iliac spines (PSISs).
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Inspection begins from the moment the patient is sighted in the waiting room. A patient who is noted to be standing is likely to have a significant disc lesion. Considerable information can be obtained from the manner in which the patient arises from a chair, moves to the consulting room, removes the shoes and clothes, gets onto the examination couch and moves when unaware of being watched.
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The spine must be adequately exposed and inspected in good light. Patients should undress to their underpants; women may retain their brassiere and it is proper to provide them with a gown that opens down the back. Note the general contour and symmetry of the back and legs, including the buttock folds, and look for muscle wasting. Note the lumbar lordosis and any abnormalities, such as lateral deviation. If lateral deviation (scoliosis) is present it is usually away from the painful side.
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Note the presence of midline moles, tufts of hair or haemangioma that might indicate an underlying congenital anomaly, such as spina bifida occulta.
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Movements of the lumbar spine
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There are three main movements of the lumbar spine. As there is minimal rotation, which mainly occurs at the thoracic spine, rotation is not so important. The movements that should be tested, and their normal ranges, are as follows:
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Measurement of the angle of movement can be made by using a line drawn between the sacrum and large prominence of the C7 spinous process.
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Have the patient relaxed, lying prone, with the head to one side and the arms by the sides. The levels of the spinous processes are identified by standing behind the patient and using your hands to identify the L4 and L5 spinous processes in relation to the top of the iliac crests. Mark the important reference points.
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Palpation, which is performed with the tips of the thumbs opposed, can commence at the spinous process of L1 and then systematically proceed distally to L5 and then over the sacrum and coccyx. Include the interspinous spaces as well as the spinous processes. When the thumbs (or other part of the hand such as the pisiforms) are applied to the spinous processes, a firm pressure is transmitted to the vertebrae by a rocking movement for three or four ‘springs’. Significant reproduction of pain is noted.
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Palpation occurs at three main sites:
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centrally (spinous processes to coccyx)
unilateral—right and left sides (1.5 cm from midline)
transverse pressure to the sides of the spinous processes (R and L)
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Straight leg raising (SLR) test (Lasègue test)
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This test is a passive test by the practitioner. The patient lies supine with both knees extended and the ankle dorsiflexed. The affected leg is raised slowly, keeping the knee extended. If sciatica with dural irritation is present, 20° to 60° of elevation causes reproduction of pain.
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The slump test is an excellent provocation test for lumbosacral pain and is more sensitive than the SLR test. It is a screening test for a disc lesion and dural tethering. It should be performed on patients who have low back pain with pain extending into the leg, and especially for posterior thigh pain.
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A positive result is reproduction of the patient’s pain, and may appear at an early stage of the test (when it is ceased).
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The patient sits on the couch in a relaxed manner with knees at the edge of the table.
The patient then slumps forward (without excessive trunk flexion), and then places the chin on the chest.
The unaffected leg is straightened.
The affected leg only is then straightened (see FIG. 38.5).
Both legs are straightened together.
The foot of the affected straightened leg is dorsiflexed.
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Note: Take care to distinguish from hamstring pain. Deflexing the neck relieves the pain of spinal origin, not hamstring pain.
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Significance of the slump test
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It is positive if the back or leg pain is reproduced.
If positive, it suggests disc disruption.
If negative, it may indicate lack of serious disc pathology.
If positive, one should approach manual therapy with caution.
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Neurological examination7
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A neurological examination is performed only when the patient’s symptoms, such as pain, paraesthesia, anaesthesia and weakness, extend into the leg.
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The importance of the neurological examination is to ensure that there is no compression of the spinal nerves from a prolapsed disc or from a tumour. This is normally tested by examining those functions that the respective spinal nerves serve, namely skin sensation, muscle power and reflex activity.
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The examination is not daunting but can be performed quickly and efficiently in 2 to 3 minutes by a methodical technique that improves with continued use. The neurological examination consists of:
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quick tests: walking on heels (L5), walking on toes (S1)
dural stretch tests: slump test, straight leg raising
specific nerve root tests (L4, L5, S1): sensation, power, reflexes
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femoral stretch test (prone, flex knee, extend hip)
motor—extension of knee
sensation—anterior thigh
reflex—knee jerk (L3, L4)
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motor: walking on toes, resisted eversion foot
sensation—little toe, most of sole
reflex—ankle jerk (S1, S2)
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The method of examining the sacroiliac and hip joints is outlined in CHAPTER 65.
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Investigations for back pain can be classified into three broad groups: front-line screening tests; specific disease investigations; and procedural and preprocedural tests.
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Plain X-rays of the lumbar spine are not routinely recommended in acute non-specific low back pain (pain <6 weeks) in the absence of ‘red flags’ as they are of limited diagnostic value and no benefits in physical function are observed.1
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These are most important for the patient presenting with chronic back pain, especially in the presence of ‘red flags’, when serious disease such as malignancy, osteoporosis, infection or spondyloarthropathy must be excluded. The screening tests for chronic pain are:
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Specific disease investigation
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peripheral arterial studies
HLA-B27 antigen test for ankylosing spondylitis and reactive arthritis
serum electrophoresis for multiple myeloma (paraprotein)
PSA for possible prostate cancer
Brucella agglutination test
blood culture for pyogenic infection and bacterial endocarditis
bone scanning to demonstrate inflammatory or neoplastic disease and infections (e.g. osteomyelitis) before changes are apparent on plain X-ray
tuberculosis studies
X-rays of shoulder and hip joint
electromyographic (EMG) studies to screen leg pain and differentiate neurological diseases from nerve compression syndromes
radioisotope scanning
technetium pyrophosphate scan of SIJ for ankylosing spondylitis
selective anaesthetic block of facet joint under image intensification
selective anaesthetic block of medial branches of posterior primary rami and other nerve roots
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Procedural and preprocedural diagnostic tests
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These tests should be kept in reserve for red flag pointers to chronic disorders, especially mechanical disorders, that remain undiagnosed and unabated, and where surgical intervention is planned for a disc prolapse requiring removal.
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Depending on availability and merit, such tests include:
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Summary of diagnostic guidelines for spinal pain
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Continuous pain (day and night) = neoplasia, especially malignancy or infection.
The big primary malignancy is multiple myeloma.
The big three metastases are from lung, breast and prostate.
The other three metastases are from thyroid, kidney/adrenal and melanoma.
Pain with standing/walking (relief with sitting) = spondylolisthesis.
Pain (and stiffness) at rest, relief with activity = inflammation.
In a young person with inflammation think of ankylosing spondylitis.
Stiffness at rest, pain with or after activity, relief with rest = osteoarthritis.
Pain provoked by activity, relief with rest = mechanical dysfunction.
Pain in bed at early morning = inflammation, depression or malignancy/infection.
Pain in periphery of limb = discogenic → radicular or vascular → claudication or spinal canal stenosis → claudication.
Pain in calf (ascending) with walking = vascular claudication.
Pain in buttock (descending) with walking = neurogenic claudication.
One disc lesion = one nerve root (exception is L5–S1 disc).
One nerve root = one disc (usually).
Two or more nerve roots—consider neoplasm.
The rule of thumb for the lumbar nerve root lesions is L3 from L2–3 disc, L4 from L3–4, L5 from L4–5 and S1 from L5–S1.
A large disc protrusion can cause bladder symptoms, either incontinence or retention.
A retroperitoneal bleed from anticoagulation therapy can give intense nerve root symptoms and signs.